Provider Demographics
NPI:1962458257
Name:SOUZA, MANUEL JOHN (MS, ANP-BC)
Entity Type:Individual
Prefix:MR
First Name:MANUEL
Middle Name:JOHN
Last Name:SOUZA
Suffix:
Gender:M
Credentials:MS, ANP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:23 BARKLEY CIR
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33907-7531
Mailing Address - Country:US
Mailing Address - Phone:239-333-1177
Mailing Address - Fax:239-333-1169
Practice Address - Street 1:23 BARKLEY CIR
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33907-7531
Practice Address - Country:US
Practice Address - Phone:239-333-1177
Practice Address - Fax:239-333-1169
Is Sole Proprietor?:No
Enumeration Date:2006-05-26
Last Update Date:2010-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA193850363LA2200X
FL9168451363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLY9368OtherBLUE SHIELD
500018529OtherRAIL ROAD MEDICARE
FL303290600Medicaid
FL303290600Medicaid